Provider Demographics
NPI:1548240484
Name:SCHNACKENBERG, ROBERT C (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:C
Last Name:SCHNACKENBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 BLANDING ST
Mailing Address - Street 2:SUITE 4
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-2922
Mailing Address - Country:US
Mailing Address - Phone:803-779-7500
Mailing Address - Fax:803-779-7522
Practice Address - Street 1:1415 BLANDING ST
Practice Address - Street 2:SUITE 4
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2922
Practice Address - Country:US
Practice Address - Phone:803-779-7500
Practice Address - Fax:803-779-7522
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-18
Last Update Date:2015-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC58162084P0804X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC058163Medicaid
SC058163Medicaid
SCD993970281Medicare ID - Type UnspecifiedMEDICARE #